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Schmidt L, Kang L, Hudson T, Martinez Quinones P, Hirsch K, DiFiore K, Haines K, Kaplan LJ, Fernandez-Moure JS. The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02358-x. [PMID: 37773464 DOI: 10.1007/s00068-023-02358-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/21/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements. METHODS We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30 mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72 h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution. RESULTS Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37 h ± 14.21 vs 59.05 h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24 h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48 h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72 h, peak sodium (Na) concentration (146.2 mEq/L ± 2.94 vs 142.8 mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1 mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days. CONCLUSIONS HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Lee Schmidt
- Department of Surgery, Division of Trauma, Acute and Critical Care Surgery, Duke University School of Medicine, Durham, NC, USA
- Icahn School of Medicine at Mount Sinai, Department of Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Lillian Kang
- Department of Surgery, Division of Trauma, Acute and Critical Care Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Taylor Hudson
- Department of Surgery, Division of Trauma, Acute and Critical Care Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Patricia Martinez Quinones
- Perelman School of Medicine, Department of Surgery, Division of Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen Hirsch
- Perelman School of Medicine, Department of Surgery, Division of Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen DiFiore
- Perelman School of Medicine, Department of Surgery, Division of Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma, Acute and Critical Care Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Lewis J Kaplan
- Perelman School of Medicine, Department of Surgery, Division of Critical Care, University of Pennsylvania, Philadelphia, PA, USA
- Surgical Services, Section of Surgical Critical Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joseph S Fernandez-Moure
- Department of Surgery, Division of Trauma, Acute and Critical Care Surgery, Duke University School of Medicine, Durham, NC, USA.
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Sun J, Zhang Y, Zhi J, Gong W. The preventive effect of oral 76% Meglumine Diatrizoate for the postoperative ileus. Biotechnol Genet Eng Rev 2023:1-16. [PMID: 36966379 DOI: 10.1080/02648725.2023.2191083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
After emergency surgery for intestinal obstruction caused by colorectal cancer, postoperative ileus (POI) is more likely to occur in the early-stage oral intake. POI incited the occurrence of postoperative complications and prolongs hospital stay. Reducing the occurrence of POI will Enhance Recovery After Surgery (ERAS). AIM The aim of this study is to observe and evaluate the preventive effect of postoperative oral administration of 76% Meglumine Diatrizoate in reducing the incidence of POI and promoting intestinal absorption during the recovery of intestinal peristalsis in patients after intestinal obstruction surgery. METHODS From October 2018 to December 2021, 94 patients (47 vs 47) with intestinalobstruction were rolled. Patients with an ASA score of 4 or higher and gastrointestinal perforation with peritonitis were excluded. After 24 hours of surgery, the patients were divided into experimental group and control group disposed of with an opaque airtight envelope method, patient-side single blind. After intestinal peristalsis recovery (2.45 ± 0.62 d vs 2.60 ± 0.68 d, P > 0.05), the experimental group was given 76% Meglumine Diatrizoate 20 ml orally 9am and the control group was given 10% glucose 20 ml for three consecutive days. POI cases, the time taken to achieve full daily oral calorie and discharge days were counted. RESULTS The time required to achieve full daily oral calorie (11.04 ± 2.70 d vs 14.09 ± 3.74 d, p < 0.05), POI cases (10/47 vs 20/47, p < 0.05) and discharge days (14.00 ± 4.89 d vs 16.77 ± 5.94 d, p < 0.05) are significantly different between the two groups. CONCLUSIONS Oral 76% Meglumine Diatrizoate is safe and effective, which can reduce the occurrence of POI, promote the recovery of intestinal absorption and shorten the length of hospital stay effectively.
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Affiliation(s)
- Jiwei Sun
- Department of Colorectal and Anal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ye Zhang
- Department of Ward Nursing, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiajun Zhi
- Department of Colorectal and Anal Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Gong
- Department of General Surgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Kola JB, Docsa T, Uray K. Mechanosensing in the Physiology and Pathology of the Gastrointestinal Tract. Int J Mol Sci 2022; 24:ijms24010177. [PMID: 36613619 PMCID: PMC9820522 DOI: 10.3390/ijms24010177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/10/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Normal gastrointestinal function relies on sensing and transducing mechanical signals into changes in intracellular signaling pathways. Both specialized mechanosensing cells, such as certain enterochromaffin cells and enteric neurons, and non-specialized cells, such as smooth muscle cells, interstitial cells of Cajal, and resident macrophages, participate in physiological and pathological responses to mechanical signals in the gastrointestinal tract. We review the role of mechanosensors in the different cell types of the gastrointestinal tract. Then, we provide several examples of the role of mechanotransduction in normal physiology. These examples highlight the fact that, although these responses to mechanical signals have been known for decades, the mechanosensors involved in these responses to mechanical signals are largely unknown. Finally, we discuss several diseases involving the overstimulation or dysregulation of mechanotransductive pathways. Understanding these pathways and identifying the mechanosensors involved in these diseases may facilitate the identification of new drug targets to effectively treat these diseases.
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Affiliation(s)
- Job Baffin Kola
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Center of Excellence, The Hungarian Academy of Sciences, 4032 Debrecen, Hungary
| | - Tibor Docsa
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Center of Excellence, The Hungarian Academy of Sciences, 4032 Debrecen, Hungary
| | - Karen Uray
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Center of Excellence, The Hungarian Academy of Sciences, 4032 Debrecen, Hungary
- Correspondence:
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Geesala R, Lin YM, Zhang K, Shi XZ. Targeting Mechano-Transcription Process as Therapeutic Intervention in Gastrointestinal Disorders. Front Pharmacol 2021; 12:809350. [PMID: 34992543 PMCID: PMC8724579 DOI: 10.3389/fphar.2021.809350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/06/2021] [Indexed: 12/16/2022] Open
Abstract
Mechano-transcription is a process whereby mechanical stress alters gene expression. The gastrointestinal (GI) tract is composed of a series of hollow organs, often encountered by transient or persistent mechanical stress. Recent studies have revealed that persistent mechanical stress is present in obstructive, functional, and inflammatory disorders and alters gene transcription in these conditions. Mechano-transcription of inflammatory molecules, pain mediators, pro-fibrotic and growth factors has been shown to play a key role in the development of motility dysfunction, visceral hypersensitivity, inflammation, and fibrosis in the gut. In particular, mechanical stress-induced cyclooxygenase-2 (COX-2) and certain pro-inflammatory mediators in gut smooth muscle cells are responsible for motility dysfunction and inflammatory process. Mechano-transcription of pain mediators such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) may lead to visceral hypersensitivity. Emerging evidence suggests that mechanical stress in the gut also leads to up-regulation of certain proliferative and pro-fibrotic mediators such as connective tissue growth factor (CTGF) and osteopontin (OPN), which may contribute to fibrostenotic Crohn's disease. In this review, we will discuss the pathophysiological significance of mechanical stress-induced expression of pro-inflammatory molecules, pain mediators, pro-fibrotic and growth factors in obstructive, inflammatory, and functional bowel disorders. We will also evaluate potential therapeutic targets of mechano-transcription process for the management of these disorders.
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Uray IP, Uray K. Mechanotransduction at the Plasma Membrane-Cytoskeleton Interface. Int J Mol Sci 2021; 22:11566. [PMID: 34768998 PMCID: PMC8584042 DOI: 10.3390/ijms222111566] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 02/08/2023] Open
Abstract
Mechanical cues are crucial for survival, adaptation, and normal homeostasis in virtually every cell type. The transduction of mechanical messages into intracellular biochemical messages is termed mechanotransduction. While significant advances in biochemical signaling have been made in the last few decades, the role of mechanotransduction in physiological and pathological processes has been largely overlooked until recently. In this review, the role of interactions between the cytoskeleton and cell-cell/cell-matrix adhesions in transducing mechanical signals is discussed. In addition, mechanosensors that reside in the cell membrane and the transduction of mechanical signals to the nucleus are discussed. Finally, we describe two examples in which mechanotransduction plays a significant role in normal physiology and disease development. The first example is the role of mechanotransduction in the proliferation and metastasis of cancerous cells. In this system, the role of mechanotransduction in cellular processes, including proliferation, differentiation, and motility, is described. In the second example, the role of mechanotransduction in a mechanically active organ, the gastrointestinal tract, is described. In the gut, mechanotransduction contributes to normal physiology and the development of motility disorders.
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Affiliation(s)
- Iván P. Uray
- Department of Clinical Oncology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
| | - Karen Uray
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
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Mazzotta E, Villalobos-Hernandez EC, Fiorda-Diaz J, Harzman A, Christofi FL. Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols. Front Pharmacol 2020; 11:583422. [PMID: 33390950 PMCID: PMC7774512 DOI: 10.3389/fphar.2020.583422] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.
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Affiliation(s)
- Elvio Mazzotta
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Fievos L. Christofi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Docsa T, Bhattarai D, Sipos A, Wade CE, Cox CS, Uray K. CXCL1 is upregulated during the development of ileus resulting in decreased intestinal contractile activity. Neurogastroenterol Motil 2020; 32:e13757. [PMID: 31722447 DOI: 10.1111/nmo.13757] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although the development of ileus is widespread and negatively impacts patient outcomes, the mechanism by which ileus develops remains unclear. The purpose of our study was to examine the contribution of myogenic mechanisms to postoperative ileus development and the involvement of inflammation in mediating intestinal smooth muscle dysfunction. METHODS Contractile activity and the effects of CXCL1 were studied in a gut manipulation model. KEY RESULTS Contraction amplitude in the ileum decreased significantly, while tone increased significantly in response to gut manipulation. Differences in contraction amplitude were affected by tetrodotoxin at earlier time points, but not at later time points. Agonist-induced contractions in the small intestine decreased significantly with ileus development. Intestinal transit slowed significantly after the induction of ileus. Myosin light chain phosphorylation was significantly decreased and edema increased significantly in the intestinal wall. Conditioned media from mechanically activated macrophages depressed intestinal contractile activity. CXCL1 (GroA) was significantly increased in the mechanically activated macrophages and intestinal smooth muscle within 1 hour after induction of ileus compared with control cells and sham animals, respectively. Treatment with CXCL1 significantly decreased contraction amplitude and agonist-induced contractile activity and increased tone in the small intestine. In the gut manipulation model, treatment with a CXCR2 antagonist prevented the decrease in agonist-induced contractile activity but not contraction amplitude. CONCLUSIONS & INFERENCES These data suggest that CXCL1, released from macrophages during intestinal wall stress, can suppress intestinal contractile activity. CXCL1 is a potential target for preventing or treating ileus in trauma patients.
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Affiliation(s)
- Tibor Docsa
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Deepa Bhattarai
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Adam Sipos
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Charles E Wade
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Charles S Cox
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Karen Uray
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Thompson TB, Riviere BM, Knepley MG. An implicit discontinuous Galerkin method for modeling acute edema and resuscitation in the small intestine. MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2019; 36:513-548. [PMID: 30722029 DOI: 10.1093/imammb/dqz001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/12/2018] [Accepted: 01/11/2019] [Indexed: 11/14/2022]
Abstract
Edema, also termed oedema, is a generalized medical condition associated with an abnormal aggregation of fluid in a tissue matrix. In the intestine, excessive edema can lead to serious health complications associated with reduced motility. A $7.5\%$ solution of hypertonic saline (HS) has been hypothesized as an effective means to reduce the effects of edema following surgery or injury. However, detailed clinical edema experiments can be difficult to implement, or costly, in practice. In this manuscript we introduce an implicit in time discontinuous Galerkin method with novel adaptations for modeling edema in the 3D layered physiology of the intestine. The model improves over early work via inclusion of the tissue intrinsic storage coefficient, and the effects of Starling overestimation for high venous pressures. Validation against a recent clinical experiment in HS resuscitation of acute edema is presented; the results support the clinical hypothesis that 7.5% HS solution may be effective in the resuscitation of acute edema formation. New results include an improved view into the effects of resuscitation on the hydrostatic pressure profile of edematous rats, effects on lumenal volume attenuation, relative fluid gain and an estimation of the impacts of both acute edema and resuscitation on intestinal motility.
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Affiliation(s)
- Travis B Thompson
- Department of Numerical Anal and Scientific Computing, Simula Research Laboratory, Fornebu, Norway
| | - Beatrice M Riviere
- Department of Computational and Applied Mathematics, Rice University, Houston, TX, USA
| | - Matthew G Knepley
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, NY, USA
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Haque M, Das A, Scott TE, Bates D, Hardman JG. Primary blast lung injury simulator: a new computerised model. J ROY ARMY MED CORPS 2018; 165:45-50. [PMID: 30077974 DOI: 10.1136/jramc-2018-000989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/03/2022]
Abstract
Mathematical modelling and computational simulation are becoming increasingly important tools in many fields of medicine where in vivo studies are expensive, difficult or impractical. This is particularly the case with primary blast lung injury, and in this paper, we give a brief overview of mathematical models before describing how we generated our blast lung injury simulator and describe some early results of its use.
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Affiliation(s)
- Mainul Haque
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
| | - A Das
- School of Engineering, University of Warwick, Warwick, UK
| | - T E Scott
- Academic Department of Military Anaesthesia and Critical Care, Ministry of Defence, Birmingham, UK
| | - D Bates
- School of Engineering, University of Warwick, Warwick, UK
| | - J G Hardman
- Anaesthesia and Critical Care, School of Medicine, University of Nottingham, Nottingham
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Lisowski ZM, Pirie RS, Blikslager AT, Lefebvre D, Hume DA, Hudson NPH. An update on equine post-operative ileus: Definitions, pathophysiology and management. Equine Vet J 2018; 50:292-303. [DOI: 10.1111/evj.12801] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 11/24/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Z. M. Lisowski
- The Roslin Institute and Royal (Dick) School of Veterinary Studies; University of Edinburgh, Easter Bush; Midlothian UK
| | - R. S. Pirie
- The Roslin Institute and Royal (Dick) School of Veterinary Studies; University of Edinburgh, Easter Bush; Midlothian UK
| | - A. T. Blikslager
- Department of Clinical Sciences; College of Veterinary Medicine; North Carolina State University; Raleigh North Carolina USA
| | - D. Lefebvre
- The Roslin Institute and Royal (Dick) School of Veterinary Studies; University of Edinburgh, Easter Bush; Midlothian UK
| | - D. A. Hume
- The Roslin Institute and Royal (Dick) School of Veterinary Studies; University of Edinburgh, Easter Bush; Midlothian UK
- Mater Research; The University of Queensland; Woolloongabba Queensland Australia
| | - N. P. H. Hudson
- The Roslin Institute and Royal (Dick) School of Veterinary Studies; University of Edinburgh, Easter Bush; Midlothian UK
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Pfortmueller CA, Schefold JC. Hypertonic saline in critical illness - A systematic review. J Crit Care 2017; 42:168-177. [PMID: 28746899 DOI: 10.1016/j.jcrc.2017.06.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/29/2017] [Accepted: 06/17/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The optimal approach to fluid management in critically ill patients is highly debated. Fluid resuscitation using hypertonic saline was used in the past for more than thirty years, but has recently disappeared from clinical practice. Here we provide an overview on the currently available literature on effects of hypertonic saline infusion for fluid resuscitation in the critically ill. METHODS Systematic analysis of reports of clinical trials comparing effects of hypertonic saline as resuscitation fluid to other available crystalloid solutions. A literature search of MEDLINE and the Cochrane Controlled Clinical trials register (CENTRAL) was conducted to identify suitable studies. RESULTS The applied search strategy produced 2284 potential publications. After eliminating doubles, 855 titles and abstracts were screened and 40 references retrieved for full text analysis. At total of 25 scientific studies meet the prespecified inclusion criteria for this study. CONCLUSION Fluid resuscitation using hypertonic saline results in volume expansion and less total infusion volume. This may be of interest in oedematous patients with intravascular volume depletion. When such strategies are employed, renal effects may differ markedly according to prior intravascular volume status. Hypertonic saline induced changes in serum osmolality and electrolytes return to baseline within a limited period in time. Sparse evidence indicates that resuscitation with hypertonic saline results in less perioperative complications, ICU days and mortality in selected patients. In conclusion, the use of hypertonic saline may have beneficial features in selected critically ill patients when carefully chosen. Further clinical studies assessing relevant clinical outcomes are warranted.
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Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland.
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Abstract
Hypertonic saline solutions (HSSs) (7.5%) are useful in the resuscitation of patients with hypovolemic shock because they provide immediate intravascular volume expansion via the delivery of a small volume of fluid, improving cardiac function. However, the effects of using 3% HSS in hypovolemic shock resuscitation are not well known. This study was designed to compare the effects of and complications associated with 3% HSS, 7.5% HSS, and standard fluid in resuscitation. In total, 294 severe trauma patients were enrolled from December 2008 to February 2012 and subjected to a double-blind randomized clinical trial. Individual patients were treated with 3% HSS (250 mL), 7.5% HSS (250 mL), or lactated Ringer's solution (LRS) (250 mL). Mean arterial pressure, blood pressure, and heart rate were monitored and recorded before fluid infusion and at 10, 30, 45, and 60 min after infusion, and the incidence of complications and survival rate were analyzed. The results indicate that 3% and 7.5% HSSs rapidly restored mean arterial pressure and led to the requirement of an approximately 50% lower total fluid volume compared with the LRS group (P < 0.001). However, a single bolus of 7.5% HSS resulted in an increase in heart rate (mean of 127 beats/min) at 10 min after the start of resuscitation. Higher rates of arrhythmia and hypernatremia were noted in the 7.5% HSS group, whereas higher risks of renal failure (P< 0.001), coagulopathy (P < 0.001), and pulmonary edema (P < 0.001) were observed in the LRS group. Neither severe electrolyte disturbance nor anaphylaxis was observed in the HSS groups. It is notable that 3% HSS had similar effects on resuscitation because both the 7.5% HSS and LRS groups but resulted in a lower occurrence of complications. This study demonstrates the efficacy and safety of 3% HSS in the resuscitation of patients with hypovolemic shock.
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Rahbar E, Akl T, Coté GL, Moore JE, Zawieja DC. Lymph transport in rat mesenteric lymphatics experiencing edemagenic stress. Microcirculation 2015; 21:359-67. [PMID: 24397756 DOI: 10.1111/micc.12112] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/05/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess lymphatic flow adaptations to edema, we evaluated lymph transport function in rat mesenteric lymphatics under normal and increased fluid volume (edemagenic) conditions in situ. METHODS Twelve rats were infused with saline (intravenous infusion, 0.2 mL/min/100 g body weight) to induce edema. We intravitally measured mesenteric lymphatic diameter and contraction frequency, as well as lymphocyte velocity and density before, during, and after infusion. RESULTS A 10-fold increase in lymphocyte velocity (0.1-1 mm/s) and a sixfold increase in flow rate (0.1-0.6 μL/min), were observed post infusion, respectively. There were also increases in contraction frequency and fractional pump flow one minute post infusion. Time-averaged wall shear stress increased 10 fold post infusion to nearly 1.5 dynes/cm(2) . Similarly, maximum shear stress rose from 5 to 40 dynes/cm(2) . CONCLUSIONS Lymphatic vessels adapted to edemagenic stress by increasing lymph transport. Specifically, the increases in lymphatic contraction frequency, lymphocyte velocity, and shear stress were significant. Lymph pumping increased post infusion, though changes in lymphatic diameter were not statistically significant. These results indicate that edemagenic conditions stimulate lymph transport via increases in lymphatic contraction frequency, lymphocyte velocity, and flow. These changes, consequently, resulted in large increases in wall shear stress, which could then activate NO pathways and modulate lymphatic transport function.
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Affiliation(s)
- Elaheh Rahbar
- Center for Translational Injury Research, Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA
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Young J, Ozisik S, Riviere B, Shamim M. A comprehensive mathematical framework for modeling intestinal smooth muscle cell contraction with applications to intestinal edema. Math Biosci 2015; 262:206-13. [PMID: 25640870 DOI: 10.1016/j.mbs.2014.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
The contraction of intestinal smooth muscle cells (ISMCs) involves many coordinated biochemical and mechanical processes. In this work, we present a framework for modeling ISMC contractility that begins with chemical models of calcium dynamics, continues with myosin light chain phosphorylation and force generation, and ends with a cell model of the ISMC undergoing contraction-relaxation. The motivation for developing this comprehensive framework is to study the effects of edema (excess fluid build-up in the muscle tissue) on ISMC contractility. The hypothesis is that more fluid equates to dilution of an external stimulis, eventually leading to reduced contractility. We compare our results to experimental data collected from normal versus edematous intestinal muscle tissue.
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Affiliation(s)
- Jennifer Young
- Computational and Applied Mathematics Department, Rice University, Houston, Texas 77005, USA
| | - Sevtap Ozisik
- Computational and Applied Mathematics Department, Rice University, Houston, Texas 77005, USA.
| | - Beatrice Riviere
- Computational and Applied Mathematics Department, Rice University, Houston, Texas 77005, USA
| | - Muhammad Shamim
- Computational and Applied Mathematics Department, Rice University, Houston, Texas 77005, USA
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Young J, Rivière B. A mathematical model of intestinal oedema formation. MATHEMATICAL MEDICINE AND BIOLOGY : A JOURNAL OF THE IMA 2014; 31:1-15. [PMID: 23036806 PMCID: PMC4854014 DOI: 10.1093/imammb/dqs025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 07/30/2012] [Accepted: 08/13/2012] [Indexed: 11/14/2022]
Abstract
Intestinal oedema is a medical condition referring to the build-up of excess fluid in the interstitial spaces of the intestinal wall tissue. Intestinal oedema is known to produce a decrease in intestinal transit caused by a decrease in smooth muscle contractility, which can lead to numerous medical problems for the patient. Interstitial volume regulation has thus far been modelled with ordinary differential equations, or with a partial differential equation system where volume changes depend only on the current pressure and not on updated tissue stress. In this work, we present a computational, partial differential equation model of intestinal oedema formation that overcomes the limitations of past work to present a comprehensive model of the phenomenon. This model includes mass and momentum balance equations which give a time evolution of the interstitial pressure, intestinal volume changes and stress. The model also accounts for the spatially varying mechanical properties of the intestinal tissue and the inhomogeneous distribution of fluid-leaking capillaries that create oedema. The intestinal wall is modelled as a multi-layered, deforming, poroelastic medium, and the system of equations is solved using a discontinuous Galerkin method. To validate the model, simulation results are compared with results from four experimental scenarios. A sensitivity analysis is also provided. The model is able to capture the final submucosal interstitial pressure and total fluid volume change for all four experimental cases, and provide further insight into the distribution of these quantities across the intestinal wall.
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Affiliation(s)
- Jennifer Young
- Computational and Applied Mathematics Department, Rice University, Houston, TX, USA
| | - Béatrice Rivière
- Computational and Applied Mathematics Department, Rice University, Houston, TX, USA
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Guo WA. The search for a magic bullet to fight multiple organ failure secondary to ischemia/reperfusion injury and abdominal compartment syndrome. J Surg Res 2013; 184:792-3. [DOI: 10.1016/j.jss.2012.06.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 06/08/2012] [Accepted: 06/14/2012] [Indexed: 11/26/2022]
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Chasing 100%: the use of hypertonic saline to improve early, primary fascial closure after damage control laparotomy. J Trauma Acute Care Surg 2013; 74:426-30; discussion 431-2. [PMID: 23354234 DOI: 10.1097/ta.0b013e31827e2a96] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Failure to achieve fascial closure after damage control laparotomy (DCL) is associated with increased morbidity and long-term disability. In addition, early closure is associated with reduces infectious, wound, and pulmonary complications. We hypothesized that hypertonic saline (HTS), which attenuates resuscitation-induced intestinal edema in animals, would improve early primary fascial closure (EPFC) rates. METHODS This is a retrospective study of trauma patients undergoing DCL, from January 2010 to July 2011. Patients in the HTS group had 30 mL/h of 3% sodium chloride as maintenance fluids while the fascia was open. Patients in the cohort group had isotonic fluids (125 mL/h). The primary outcome, EPFC, was defined as primary fascial closure by postinjury day 7. RESULTS Seventy-seven patients underwent DCL (23 received HTS and 54 received isotonic fluids). There were no differences in demographics, injury severity, or pre-intensive care unit vitals, laboratories, fluids, or transfusions. Median fluids in the first 24 hours were lower in the HTS group (3.9 vs. 7.8 L, p < 0.001). Times to fascial closure were shorter in those receiving HTS (34 vs. 49 hours, p < 0.001), as were the rates of closure at first take back (78% vs. 53%, p = 0.036). The primary outcome of EPFC was higher in the HTS group compared with standard fluids (100% vs. 76%, p = 0.010). At discharge, the HTS group had a 96% primary fascial closure rate compared with 80% with standard fluids. CONCLUSION The use of 3% HTS as maintenance fluids after DCL was associated with 100% EPFC. HTS may be used as an adjunct to facilitate fascial closure in patients undergoing DCL. LEVEL OF EVIDENCE Diagnostic study, level III.
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Chu J, Pham NT, Olate N, Kislitsyna K, Day MC, LeTourneau PA, Kots A, Stewart RH, Laine GA, Cox CS, Uray K. Biphasic regulation of myosin light chain phosphorylation by p21-activated kinase modulates intestinal smooth muscle contractility. J Biol Chem 2012; 288:1200-13. [PMID: 23161543 DOI: 10.1074/jbc.m112.370718] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Supraphysiological mechanical stretching in smooth muscle results in decreased contractile activity. However, the mechanism is unclear. Previous studies indicated that intestinal motility dysfunction after edema development is associated with increased smooth muscle stress and decreased myosin light chain (MLC) phosphorylation in vivo, providing an ideal model for studying mechanical stress-mediated decrease in smooth muscle contraction. Primary human intestinal smooth muscle cells (hISMCs) were subjected to either control cyclical stretch (CCS) or edema (increasing) cyclical stretch (ECS), mimicking the biophysical forces in non-edematous and edematous intestinal smooth muscle in vivo. ECS induced significant decreases in phosphorylation of MLC and MLC phosphatase targeting subunit (MYPT1) and a significant increase in p21-activated kinase (PAK) activity compared with CCS. PAK regulated MLC phosphorylation in an activity-dependent biphasic manner. PAK activation increased MLC and MYPT1 phosphorylation in CCS but decreased MLC and MYPT1 phosphorylation in hISMCs subjected to ECS. PAK inhibition had the opposite results. siRNA studies showed that PAK1 plays a critical role in regulating MLC phosphorylation in hISMCs. PAK1 enhanced MLC phosphorylation via phosphorylating MYPT1 on Thr-696, whereas PAK1 inhibited MLC phosphorylation via decreasing MYPT1 on both Thr-696 and Thr-853. Importantly, in vivo data indicated that PAK activity increased in edematous tissue, and inhibition of PAK in edematous intestine improved intestinal motility. We conclude that PAK1 positively regulates MLC phosphorylation in intestinal smooth muscle through increasing inhibitory phosphorylation of MYPT1 under physiologic conditions, whereas PAK1 negatively regulates MLC phosphorylation via inhibiting MYPT1 phosphorylation when PAK activity is increased under pathologic conditions.
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Affiliation(s)
- Ji Chu
- Department of Pediatric Surgery, University of Texas Medical School, Houston, Texas 77030, USA
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Rahbar E, Weimer J, Gibbs H, Yeh AT, Bertram CD, Davis MJ, Hill MA, Zawieja DC, Moore JE. Passive pressure-diameter relationship and structural composition of rat mesenteric lymphangions. Lymphat Res Biol 2012; 10:152-63. [PMID: 23145980 DOI: 10.1089/lrb.2011.0015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Lymph flow depends on both the rate of lymph production by tissues and the extent of passive and active pumping. Here we aim to characterize the passive mechanical properties of a lymphangion in both mid-lymphangion and valve segments to assess regional differences along a lymphangion, as well as evaluating its structural composition. METHODS AND RESULTS Mesenteric lymphatic vessels were isolated and cannulated in a microchamber for pressure-diameter (P-D) testing. Vessels were inflated from 0 to 20 cmH(2)O at a rate of 4 cmH(2)O/min, and vessel diameter was continuously tracked, using an inverted microscope, video camera, and custom LabVIEW program, at both mid-lymphangion and valve segments. Isolated lymphatic vessels were also pressure-fixed at 2 and 7 cmH(2)O and imaged using a nonlinear optical microscope (NLOM) to obtain collagen and elastin structural information. We observed a highly nonlinear P-D response at low pressures (3-5 cmH(2)O), which was modeled using a three-parameter constitutive equation. No significant difference in the passive P-D response was observed between mid-lymphangion and valve regions. NLOM imaging revealed an inner elastin layer and outer collagen layer at all locations. Lymphatic valve leaflets were predominantly elastin with thick axially oriented collagen bands at the insertion points. CONCLUSIONS We observed a highly nonlinear P-D response at low pressures (3-5 cmH(2)O) and developed the first constitutive equation to describe the passive P-D response for a lymphangion. The passive P-D response did not vary among regions, in agreement with the composition of elastin and collagen in the lymphatic wall.
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Affiliation(s)
- Elaheh Rahbar
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas 77843-3120, USA
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Shah SK, Jimenez F, Letourneau PA, Walker PA, Moore-Olufemi SD, Stewart RH, Laine GA, Cox CS. Strategies for modulating the inflammatory response after decompression from abdominal compartment syndrome. Scand J Trauma Resusc Emerg Med 2012; 20:25. [PMID: 22472164 PMCID: PMC3352320 DOI: 10.1186/1757-7241-20-25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 04/03/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Management of the open abdomen is an increasingly common part of surgical practice. The purpose of this review is to examine the scientific background for the use of temporary abdominal closure (TAC) in the open abdomen as a way to modulate the local and systemic inflammatory response, with an emphasis on decompression after abdominal compartment syndrome (ACS). METHODS A review of the relevant English language literature was conducted. Priority was placed on articles published within the last 5 years. RESULTS/CONCLUSION Recent data from our group and others have begun to lay the foundation for the concept of TAC as a method to modulate the local and/or systemic inflammatory response in patients with an open abdomen resulting from ACS.
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Affiliation(s)
- Shinil K Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
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21
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Chu J, Miller CT, Kistlitsyna K, Laine GA, Stewart RH, Cox CS, Uray KS. Decreased myosin phosphatase target subunit 1(MYPT1) phosphorylation via attenuated rho kinase and zipper-interacting kinase activities in edematous intestinal smooth muscle. Neurogastroenterol Motil 2012; 24:257-66, e109. [PMID: 22235829 PMCID: PMC3321580 DOI: 10.1111/j.1365-2982.2011.01855.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal edema development after trauma resuscitation inhibits intestinal motility which results in ileus, preventing enteral feeding and compromising patient outcome. We have shown previously that decreased intestinal motility is associated with decreased smooth muscle myosin light chain (MLC) phosphorylation. The purpose of the present study was to investigate the mechanism of edema-induced decreases in MLC in a rodent model of intestinal edema. METHODS Intestinal edema was induced by a combination of resuscitation fluid administration and mesenteric venous hypertension. Sham operated animals served as controls. Contractile activity and alterations in the regulation of MLC including the regulation of MLC kinase (MLCK) and MLC phosphatase (MLCP) were measured. KEY RESULTS Contraction amplitude and basal tone were significantly decreased in edematous intestinal smooth muscle compared with non-edematous tissue. Calcium sensitivity was also decreased in edematous tissue compared with non-edematous intestinal smooth muscle. Although inhibition of MLCK decreased contractile activity significantly less in edematous tissue compared with non-edematous tissue, MLCK activity in tissue lysates was not significantly different. Phosphorylation of MYPT was significantly lower in edematous tissue compared with non-edematous tissue. In addition, activities of both rho kinase and zipper-interacting kinase were significantly lower in edematous tissue. CONCLUSIONS & INFERENCES We conclude from these data that interstitial intestinal edema inhibits MLC phosphorylation predominantly by decreasing inhibitory phosphorylation of the MLC targeting subunit (MYPT1) of MLC phosphatase via decreased ROCK and ZIPK activities, resulting in more MLC phosphatase activity.
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Affiliation(s)
- Ji Chu
- Department of Pediatric Surgery, University of Texas Medical School at Houston
| | | | - Karina Kistlitsyna
- Department of Pediatric Surgery, University of Texas Medical School at Houston
| | | | | | - Charles S. Cox
- Department of Pediatric Surgery, University of Texas Medical School at Houston,Michael E. DeBakey Institute, Texas A&M University
| | - Karen S. Uray
- Department of Pediatric Surgery, University of Texas Medical School at Houston,Michael E. DeBakey Institute, Texas A&M University
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Fielding CL, Dechant JE. Colic in competing endurance horses presenting to referral centres: 36 cases. Equine Vet J 2011; 44:472-5. [PMID: 22050046 DOI: 10.1111/j.2042-3306.2011.00462.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
REASONS FOR PERFORMING STUDY Colic is a common reason for elimination from equine endurance competitions and has recently been identified as the leading cause of mortality in this group of horses. Hydration and electrolyte derangements are often severe, but are probably related to endurance exercise and not necessarily the episode of colic. Better understanding of the causes of colic and the expected outcome is needed to guide treatment decisions in endurance horses. OBJECTIVES To describe the history, case details, clinical examination, laboratory, treatment and outcomes for horses presenting to equine referral centres for treatment of colic associated with endurance competition and to identify variables associated with prolonged hospitalisation. METHODS Thirty-six horses from 2 equine referral centres were included in the analysis. In addition to descriptive statistics, Cox proportional hazards models were used to evaluate factors associated with length of hospitalisation. RESULTS A diagnosis of open or ileus was made in the majority of horses (56%). Salmonellosis and enteritis (Salmonella negative) were also recognised (16%). Exploratory abdominal surgery was performed in 5 of the horses. Only one of 36 horses did not survive to discharge. Previous eliminations from competition (negative association) and total i.v. fluids within the first 24 h (positive association) of admission were both associated with length of hospitalisation. CONCLUSIONS Endurance horses with colic typically respond to medical treatment but in some cases hospitalisation may be prolonged. The role of Salmonella infections in endurance horses with colic requires further research. POTENTIAL RELEVANCE Despite potentially severe clinical and laboratory derangements, equine practitioners should make owners aware that the prognosis for competing endurance horses with colic is good when treated appropriately.
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Affiliation(s)
- C L Fielding
- Loomis Basin Equine Medical Center, Loomis, California and University of California, Davis, School of Veterinary Medicine, Davis, California, USA.
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Uray KS, Shah SK, Radhakrishnan RS, Jimenez F, Walker PA, Stewart RH, Laine GA, Cox CS. Sodium hydrogen exchanger as a mediator of hydrostatic edema-induced intestinal contractile dysfunction. Surgery 2011; 149:114-25. [PMID: 20553904 DOI: 10.1016/j.surg.2010.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Accepted: 04/13/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Resuscitation-induced intestinal edema is associated with early and profound mechanical changes in intestinal tissue. We hypothesize that the sodium hydrogen exchanger (NHE), a mechanoresponsive ion channel, is a mediator of edema-induced intestinal contractile dysfunction. METHODS An animal model of hydrostatic intestinal edema was used for all experiments. NHE isoforms 1-3 mRNA and protein were evaluated. Subsequently, the effects of NHE inhibition (with 5-(N-ethyl-N-isopropyl) amiloride [EIPA]) on wet-to-dry ratios, signal transduction and activator of transcription (STAT)-3, intestinal smooth muscle myosin light chain (MLC) phosphorylation, intestinal contractile activity, and intestinal transit were measured. RESULTS NHE1-3 mRNA and protein levels were increased significantly in the small intestinal mucosa with the induction of intestinal edema. The administration of EIPA, an NHE inhibitor, attenuated validated markers of intestinal contractile dysfunction induced by edema as measured by decreased STAT-3 activation, increased MLC phosphorylation, improved intestinal contractile activity, and enhanced intestinal transit. CONCLUSION The mechanoresponsive ion channel NHE may mediate edema-induced intestinal contractile dysfunction, possibly via a STAT-3 related mechanism.
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Affiliation(s)
- Karen S Uray
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX 77030, USA
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Shah SK, Moore-Olufemi SD, Uray KS, Jimenez F, Walker PA, Xue H, Stewart RH, Laine GA, Cox CS. A murine model for the study of edema induced intestinal contractile dysfunction. Neurogastroenterol Motil 2010; 22:1132-e290. [PMID: 20591104 PMCID: PMC2939955 DOI: 10.1111/j.1365-2982.2010.01546.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We have published extensively regarding the effects of edema on intestinal contractile function. However, we have found the need to expand our model to mice to take advantage of the much larger arsenal of research support, especially in terms of transgenic mouse availability and development. To that end, we have developed and validated a hydrostatic intestinal edema model in mice. METHODS Male C57 Black 6 mice were subjected to a combination of high volume crystalloid resuscitation and mesenteric venous hypertension in an effort to induce hydrostatic intestinal edema. Wet to dry ratios, myeloperoxidase activity, mucosal injury scoring, STAT-3 nuclear activation, phosphorylated STAT-3 levels, NF-κB nuclear activation, myosin light chain phosphorylation, intestinal contractile activity, and intestinal transit were measured to evaluate the effects of the model. KEY RESULTS High volume crystalloid resuscitation and mesenteric venous hypertension resulted in the development of significant intestinal edema without an increase in myeloperoxidase activity or mucosal injury. Edema development was associated with increases in STAT-3 and NF-κB nuclear activation as well as phosphorylated STAT-3. There was a decrease in myosin light chain phosphorylation, basal and maximally stimulated intestinal contractile activity, and intestinal transit. CONCLUSION & INFERENCES Hydrostatic edema in mice results in activation of a signal transduction profile that culminates in intestinal contractile dysfunction. This novel model allows for advanced studies into the pathogenesis of hydrostatic edema induced intestinal contractile dysfunction.
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Affiliation(s)
- Shinil K. Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Stacey D. Moore-Olufemi
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Karen S. Uray
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A & M University, College Station, Texas
| | - Fernando Jimenez
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Peter A. Walker
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Hasen Xue
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Randolph H. Stewart
- Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A & M University, College Station, Texas
| | - Glen A. Laine
- Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A & M University, College Station, Texas
| | - Charles S. Cox
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A & M University, College Station, Texas
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Clinical experience using 5% hypertonic saline as a safe alternative fluid for use in trauma. ACTA ACUST UNITED AC 2010; 68:1172-7. [PMID: 20453771 DOI: 10.1097/ta.0b013e3181d76d40] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Published experience of hypertonic saline (HTS) use in resuscitation has described the use of commercially unavailable 7.5% solutions. The purpose of this study was to compare our experience with the administration of commercially available 5% HTS solution with that of well-matched controls who did not receive HTS. METHODS Prospective observational study of 51 trauma patients receiving 500 mL of 5% HTS during initial resuscitation. Patients who received HTS were 1:2 matched using age, gender, Injury Severity Score, Coma Score, Head Abbreviated Injury Scale, and injury mechanism to trauma patients who did not receive HTS. The laboratory values and outcomes of the two groups were compared. RESULTS Patients receiving HTS demonstrated no difference from the matched cohort in mean pH, international normalized ratio, or p/f ratios at 8 hours or 24 hours. The mean serum sodium of the HTS group was higher than controls at 8 hours (143.1 vs. 150.1 mg/dL, p < 0.001) and remained significantly more increased for 3 days without any adverse sequelae related to hypernatremia. No difference in mortality was noted between the two groups. A trend in decreased mortality was observed in patients with Coma Score <or=8 and Head Abbreviated Injury Scale score >or=3 (25.0% vs. 42.5%). The mean ventilator days were 7.3 for HTS group and 9.2 for the non-HTS group. CONCLUSION Although serum sodium remained increased for several days after HTS administration, no adverse sequelae as a result of hypernatremia resulted. Commercially available 5% HTS solution is safe for use in the resuscitation of trauma patients and may improve outcomes in a selected subset of patients with head injury.
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Abstract
BACKGROUND : Current abdominal compartment syndrome (ACS) models rely on intraperitoneal instillation of fluid, air, and other space-occupying substances. Although this allows for the study of the effects of increased abdominal pressure, it poorly mimics its pathogenesis. We have developed the first reported large animal model of ACS incorporating hemorrhagic shock/resuscitation. METHODS : Hemorrhagic shock was induced and maintained (1 hour) in 12 Yorkshire swine by bleeding to a mean arterial pressure (MAP) of 50 mm Hg. The collected blood plus two additional volumes of crystalloid was then reinfused. Mesenteric venous hypertension was induced by tightening a previously placed portal vein snare in a nonocclusive manner to mimic the effects of abdominal packing. Crystalloids were infused to maintain MAP. Hemodynamic measurements, abdominal pressure, peak inspiratory pressures, urine output, and blood chemistries were measured sequentially. Animals were studied for 36 hours after decompression. RESULTS : ACS (intra-abdominal pressure of > or =20 mm Hg with new organ dysfunction) developed in all animals. There were significant increases in peak inspiratory pressure, central venous pressure, and pulmonary artery pressure and decreases in MAP upon development of ACS. Urine output was significantly decreased before decompression. Mean blood lactate decreased and base excess increased significantly after decompression. CONCLUSIONS : We have created the first reported physiologic animal ACS model incorporating hemorrhagic shock/resuscitation and the effects of damage control surgery.
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Abstract
OBJECTIVE To investigate the molecular mechanisms leading to edema-induced decreases in intestinal smooth muscle myosin light-chain phosphorylation. Intestinal interstitial edema often develops during abdominal surgery and after fluid resuscitation in trauma patients. Intestinal edema causes decreased intestinal contractile activity via decreased intestinal smooth muscle myosin light-chain phosphorylation, leading to slower intestinal transit. Interstitial edema development is a complex phenomenon, resulting in many changes to the interstitial environment surrounding intestinal smooth muscle cells. Thus, the mechanism(s) by which intestinal edema development causes intestinal dysfunction are likely to be multifactorial. DESIGN Randomized animal study. SETTING University laboratory. SUBJECTS Male Sprague-Dawley rats, weighing 250-350 g. INTERVENTION Studies were performed in a rat model in which a combination of mesenteric venous hypertension and administration of resuscitative fluids induces intestinal edema, mimicking the clinical setting of damage control resuscitation. MEASUREMENTS AND MAIN RESULTS Microarray analysis of edematous intestinal smooth muscle combined with an in silico search for overrepresented transcription factor binding sites revealed the involvement of nuclear factor-kappaB in edema-induced intestinal dysfunction. Nuclear factor-kappaB deoxyribonucleic acid binding activity was significantly increased in edematous intestinal smooth muscle compared with controls. Inhibition of nuclear factor-kappaB activation blocked edema-induced decreases in basal intestinal contractile activity. Inhibition of nuclear factor-kappaB activation also attenuated edema-induced decreases in myosin light-chain phosphorylation. CONCLUSIONS We conclude that intestinal edema activates nuclear factor-kappaB, which, in turn, triggers a gene regulation program that eventually leads to decreased myosin light-chain phosphorylation and, thus, decreased intestinal contractile activity.
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Abstract
Hemorrhage remains a major cause of preventable death following both civilian and military trauma. The goals of resuscitation in the face of hemorrhagic shock are restoring end-organ perfusion and maintaining tissue oxygenation while attempting definitive control of bleeding. However, if not performed properly, resuscitation can actually exacerbate cellular injury caused by hemorrhagic shock, and the type of fluid used for resuscitation plays an important role in this injury pattern. This article reviews the historical development and scientific underpinnings of modern resuscitation techniques. We summarized data from a number of studies to illustrate the differential effects of commonly used resuscitation fluids, including isotonic crystalloids, natural and artificial colloids, hypertonic and hyperoncotic solutions, and artificial oxygen carriers, on cellular injury and how these relate to clinical practice. The data reveal that a uniformly safe, effective, and practical resuscitation fluid when blood products are unavailable and direct hemorrhage control is delayed has been elusive. Yet, it is logical to prevent this cellular injury through wiser resuscitation strategies than attempting immunomodulation after the damage has already occurred. Thus, we describe how some novel resuscitation strategies aimed at preventing or ameliorating cellular injury may become clinically available in the future.
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Affiliation(s)
- Heena P Santry
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Shah SK, Fogle LN, Aroom KR, Gill BS, Moore-Olufemi SD, Jimenez F, Uray KS, Walker PA, Stewart RH, Laine GA, Cox CS. Hydrostatic intestinal edema induced signaling pathways: potential role of mechanical forces. Surgery 2010; 147:772-9. [PMID: 20097396 DOI: 10.1016/j.surg.2009.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 11/24/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hydrostatic intestinal edema initiates a signal transduction cascade that results in smooth muscle contractile dysfunction. Given the rapid and concurrent alterations in the mechanical properties of edematous intestine observed with the development of edema, we hypothesize that mechanical forces may serve as a stimulus for the activation of certain signaling cascades. We sought to examine whether isolated similar magnitude mechanical forces induced the same signal transduction cascades associated with edema. METHODS The distal intestine from adult male Sprague Dawley rats was stretched longitudinally for 2 h to 123% its original length, which correlates with the interstitial stress found with edema. We compared wet-to-dry ratios, myeloperoxidase activity, nuclear signal transduction and activator of transcription (STAT)-3 and nuclear factor (NF)-kappa B DNA binding, STAT-3 phosphorylation, myosin light chain phosphorylation, baseline and maximally stimulated intestinal contractile strength, and inducible nitric oxide synthase (iNOS) and sodium hydrogen exchanger 1-3 messenger RNA (mRNA) in stretched and adjacent control segments of intestine. RESULTS Mechanical stretch did not induce intestinal edema or an increase in myeloperoxidase activity. Nuclear STAT-3 DNA binding, STAT-3 phosphorylation, and nuclear NF-kappa B DNA binding were significantly increased in stretched seromuscular samples. Increased expression of sodium hydrogen exchanger 1 was found but not an increase in iNOS expression. Myosin light chain phosphorylation was significantly decreased in stretched intestine as was baseline and maximally stimulated intestinal contractile strength. CONCLUSION Intestinal stretch, in the absence of edema/inflammatory/ischemic changes, leads to the activation of signaling pathways known to be altered in intestinal edema. Edema may initiate a mechanotransductive cascade that is responsible for the subsequent activation of various signaling cascades known to induce contractile dysfunction.
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Affiliation(s)
- Shinil K Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX, USA
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Radhakrishnan RS, Shah SK, Lance SH, Radhakrishnan HR, Xue H, Radhakrishnan GL, Ramaswamy US, Walker PA, Uray KS, Laine GA, Stewart RH, Cox CS. Hypertonic saline alters hydraulic conductivity and up-regulates mucosal/submucosal aquaporin 4 in resuscitation-induced intestinal edema. Crit Care Med 2009; 37:2946-52. [PMID: 19770732 DOI: 10.1097/ccm.0b013e3181ab878b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To characterize membrane conductivity by applying mathematical modeling techniques and immunohistochemistry and to localize and predict areas of the bowel where aquaporins may be associated with edema resolution/prevention associated with hypertonic saline. Intestinal edema induced by resuscitation and mesenteric venous hypertension impairs intestinal transit/contractility. Hypertonic saline decreases intestinal edema and improves transit. Aquaporins are water transport membrane proteins that may be up-regulated with edema and/or hypertonic saline. DESIGN Laboratory study. SETTING University research laboratory. SUBJECTS Male Sprague Dawley rats, weighing 270 to 330 g. INTERVENTIONS Rats were randomized to control (with and without hypertonic saline) and mesenteric venous hypertension with either 80 mL/kg normal saline (RESUS + VH + VEH) or 80 mL/kg normal saline with hypertonic saline (RESUS + VH + HTS). After 6 hrs, intestinal wet/dry ratios, urine output, peritoneal fluid, and intraluminal fluid were measured. Hydraulic conductivity was calculated from our previously known and published pressure-flow data. The cDNA microarray, Western blot, polymerase chain reaction, and immunohistochemistry studies were conducted for candidate aquaporins and distribution in intestinal edema resolution. MEASUREMENTS AND MAIN RESULTS Hypertonic saline decreased edema and increased urine, intraluminal, and peritoneal fluid volume. RESUS + VH favors fluid flux into the interstitium. Hypertonic saline causes increased hydraulic conductivity at the seromuscular and mucosal surfaces at the same time limiting flow into the interstitium. This is associated with increased aquaporin 4 expression in the intestinal mucosa and submucosa. CONCLUSIONS Hypertonic saline mitigates intestinal edema development and promotes fluid redistribution secondary to increased membrane conductivity at the mucosal and seromuscular surfaces. This is associated with up-regulation of aquaporin 4 gene expression and protein. Aquaporin 4 may be a useful therapeutic target for strategies to enhance edema resolution.
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Affiliation(s)
- Ravi S Radhakrishnan
- Department of Pediatric Surgery and Trauma Research Center, University of Texas Medical School at Houston, Houston, TX, USA
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Shah SK, Uray KS, Stewart RH, Laine GA, Cox CS. Resuscitation-induced intestinal edema and related dysfunction: state of the science. J Surg Res 2009; 166:120-30. [PMID: 19959186 DOI: 10.1016/j.jss.2009.09.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 07/24/2009] [Accepted: 09/04/2009] [Indexed: 11/26/2022]
Abstract
High volume resuscitation and damage control surgical methods, while responsible for significantly decreasing morbidity and mortality from traumatic injuries, are associated with pathophysiologic derangements that lead to subsequent end organ edema and dysfunction. Alterations in hydrostatic and oncotic pressures frequently result in intestinal edema and subsequent dysfunction. The purpose of this review is to examine the principles involved in the development of intestinal edema, current and historical models for the study of edema, effects of edema on intestinal function (particularly ileus), molecular mediators governing edema-induced dysfunction, potential role of mechanotransduction , and therapeutic effects of hypertonic saline. We review the current state of the science as it relates to resuscitation induced intestinal edema and resultant dysfunction.
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Affiliation(s)
- Shinil K Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas 77030, USA
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WHAT'S NEW IN SHOCK, MAY 2008? Shock 2008; 29:541-2. [DOI: 10.1097/shk.0b013e31816e2c98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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